Meade-Aguilar José A, Varela-Martinez Yessica N, Ramirez-Eguía Sandra P, Sanchez-Hurtado Edgar, Mondragón-Labelle Tania O, Bautista-Aguilar Gabriela A, Deloya-Tomas Ernesto, Phinder-Puente Marian E, Pérez Nieto Orlando R
Department of Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
Internal Medicine Department, Hospital General Regional IMSS No. 2 El Marqués, Querétaro, México.
SAGE Open Med Case Rep. 2023 Jul 6;11:2050313X231185617. doi: 10.1177/2050313X231185617. eCollection 2023.
The coronavirus disease 2019 has been demonstrated to be a trigger for multiple immune-mediated diseases, such as antineutrophil cytoplasmic antibody-associated vasculitis. Associated vasculitis consists of rare autoimmune disorders that predominantly affect small vessels, leading to endothelial injury and tissue damage. We present a case of a newly diagnosed microscopic polyangiitis temporally associated with coronavirus disease 2019 infection in a previously healthy woman and a literature review. A 66-year-old female presented to the Emergency Room with fever, edema on her legs, productive cough, dyspnea, and hemoptysis. A chest computerized tomography scan revealed bilateral diffuse alveolar opacities with the appearance of diffuse alveolar hemorrhage. Blood analysis revealed a moderate normocytic, normochromic anemia with a hemoglobin of 6.6 g/dL, platelet count of 347 k/dL, leucocytes of 12,000/dL, a creatinine of 3.91 mg/dL (basal Cr: 0.9 mg/dL), and a Blood Urine Nnitrogen of 78 mg/dL. A urine sediment demonstrated glomerular hematuria, with mixed shapes of red blood cells. She was admitted to the intensive care unit and a bedside bronchoscopy revealed progressive bleeding with a bronchioalveolar lavage positive for diffuse alveolar hemorrhage. Given the critical involvement of the lungs and kidney function, the diagnostic approach revealed a positive p-anti-neutrophil cytoplasmic antibody on immunofluorescence and an anti-MPO (myeloperoxidase) level of 124.6 IU/mL. A renal biopsy demonstrated pauciimmune focal and segmental glomerulosclerosis. A diagnosis of microscopic polyangiitis triggered by severe acute respiratory syndrome coronavirus 2 infection was made, and immediate treatment with pulse-dose steroids and cyclophosphamide was initiated. The patient needed renal replacement therapy and was discharged for follow-up with nephrology and rheumatology services. The diagnostic approach of associated vasculitis can be more challenging in the coronavirus disease era. Atypical features in the pulmonary imaging and a rapid deterioration of the renal function should arise the clinical suspicion of the presence of an added condition to the coronavirus disease infection. Autoimmune conditions such as associated vasculitis should be evaluated even in the absence of previous autoimmune history. Prompt diagnosis and treatments must be prioritized to avoid end-organ definite damage. Further, larger and more collaborative studies are needed to confirm the potential role of coronavirus disease 2019 as a trigger of associated vasculitis.
2019冠状病毒病已被证明是多种免疫介导疾病的诱因，如抗中性粒细胞胞浆抗体相关性血管炎。相关性血管炎是一类罕见的自身免疫性疾病，主要影响小血管，导致内皮损伤和组织损害。我们报告一例既往健康女性新诊断的显微镜下多血管炎，其在时间上与2019冠状病毒病感染相关，并进行文献综述。一名66岁女性因发热、腿部水肿、咳痰、呼吸困难和咯血就诊于急诊室。胸部计算机断层扫描显示双侧弥漫性肺泡混浊，表现为弥漫性肺泡出血。血液分析显示中度正细胞正色素性贫血，血红蛋白为6.6 g/dL，血小板计数为347 k/dL，白细胞为12,000/dL，肌酐为3.91 mg/dL（基础肌酐：0.9 mg/dL），血尿素氮为78 mg/dL。尿沉渣显示肾小球性血尿，红细胞形态多样。她被收入重症监护病房，床旁支气管镜检查显示进行性出血，支气管肺泡灌洗显示弥漫性肺泡出血阳性。鉴于肺部和肾功能的严重受累，诊断方法显示免疫荧光法p-抗中性粒细胞胞浆抗体阳性，抗髓过氧化物酶（MPO）水平为124.6 IU/mL。肾活检显示寡免疫性局灶节段性肾小球硬化。诊断为严重急性呼吸综合征冠状病毒2感染引发的显微镜下多血管炎，并立即开始使用冲击剂量的类固醇和环磷酰胺治疗。患者需要肾脏替代治疗，出院后由肾病科和风湿科进行随访。在2019冠状病毒病时代，相关性血管炎的诊断方法可能更具挑战性。肺部影像学的非典型特征和肾功能的快速恶化应引起临床对2019冠状病毒病感染合并其他疾病的怀疑。即使没有既往自身免疫病史，也应评估自身免疫性疾病，如相关性血管炎。必须优先进行及时诊断和治疗，以避免终末器官的确定性损害。此外，需要开展更大规模、更具协作性的研究，以确认2019冠状病毒病作为相关性血管炎诱因的潜在作用。
